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Patient Safety Tip of the Week

August 23, 2022

Yes, There is a Proper Way to Assess Orthostatic Hypotension



Year after year we have seen cases of falls or syncope in which the potential role of orthostatic hypotension has been inadequately assessed. Even when orthostatic hypotension is considered as a potential contributory factor, we often see that it is excluded because the correct assessment was never performed. The proper technique for checking orthostatic signs is as follows:


First, have the patient lie supine for at least 5 minutes prior to beginning measurements. One should then measure both the blood pressure and pulse of the patient in the supine position. Then, after telling the patient what you will be doing and asking him to tell you about symptoms such as dizziness or graying out of vision that might occur when upright, one stands the patient upright (being sure you can safely lie him down if they do become symptomatic!). The pulse should be measured first on standing since what the heart rate does in response to orthostatic hypotension may provide clues to the etiology of the orthostatic hypotension. The blood pressure is then recorded. If there is a drop in blood pressure, one should keep the patient upright (unless symptomatic) and record the blood pressure and pulse again at 1-2 minutes intervals until it has stabilized.


Why do all this? We ran an autonomic nervous system lab for many years and saw many patients with symptomatic orthostatic hypotension. The reason for having the patient lie supine for a significant period prior to first BP determination is that patients with some neurological disorders, such as Multiple System Atrophy, will have supine hypertension in addition to orthostatic hypotension. The magnitude of their blood pressure drop will be much greater when going from supine to standing rather than sitting to standing. The reason for checking the pulse immediately on standing may provide clues to the etiology of any orthostatic hypotension. If the autonomic nervous system is intact, you should see a prompt increase in heart rate that plateaus and then stabilizes. That pattern might be seen in patients whose orthostatic hypotension is caused by dehydration, hypovolemia, some drugs, and other conditions. On the other hand, the lack of such compensatory tachycardia might be seen in patients with impaired autonomic nervous systems, such as those with diabetic polyneuropathy.


So, why is this a patient safety issue? The best time to determine the primary cause of a fall or factors contributing to a fall is immediately following a fall or syncopal episode. We always recommend assessment for orthostatic hypotension at the time of the event. But you may also proactively identify orthostatic hypotension as a risk factor for falls and take steps to reduce that risk.


A recent study (Juraschek 2022) sheds light on the importance of proper assessment for orthostatic hypotension. The Study to Understand Fall Reduction and Vitamin D in You (STURDY) was a randomized trial of vitamin D3 supplementation and fall in community-based adults aged ≥70 years at high risk of falls. Participants had blood pressure measurements going both from sitting-to-standing and supine-to-standing.


Mean BP increased 3.5 mmHg from sitting to standing but decreased with supine to standing (mean change: −3.7 mmHg). Orthostatic hypotension (defined in this study as a drop in systolic or diastolic BP of at least 20 or 10 mmHg) was detected in 2.1% of seated versus 15.0% of supine assessments (P < 0.001). While supine and seated OH were not associated with falls (HR1.55 vs 0.69), supine systolic OH was associated with higher fall risk (HR 1.77). Supine OH was associated with self-reported fainting, blacking out, seeing spots and room spinning in the prior month, while sitting OH was not associated with any symptoms They authors conclude that supine OH was more frequent, associated with orthostatic symptoms, and potentially more predictive of falls than seated OH.


Measuring the supine to standing BP and P thus is important in the elderly population (or other population you might consider at risk for falls). If you find significant orthostatic hypotension you may need to take steps to reduce the magnitude of the BP drop or at least advise the patient about the risks of rapidly going from supine to standing.


Doing a proper orthostatic assessment immediately in a patient with syncope or unexplained fall is also important because some of the conditions causing it may be transitory. For example, micturition syncope has often been described in young, otherwise healthy, military recruits. After a night of alcohol consumption, they get vasodilation and diuresis (alcohol inhibits their antidiuretic hormone), lay down to sleep, then arise and urinate in the standing position. The drop in blood pressure from standing is exaggerated by a reduction in sympathetic tone from emptying the bladder and the patient faints. By later that day the patient may no longer have orthostatic hypotension and you will have missed an important diagnostic finding if you did not check for orthostatic hypotension shortly after the syncope of fall.



Some of our prior columns stressing orthostatic hypotension and falls:

·       April 16, 2007 “Falls with Injury”

·       January 15, 2013 “Falls on Inpatient Psychiatry”

·       February 16, 2016 “Fall Prevention Failing?”

·       March 14, 2017 “More on Falls on Inpatient Psychiatry”






Juraschek SP, Appel LJ, Mitchell CM, et al. Comparison of supine and seated orthostatic hypotension assessments and their association with falls and orthostatic symptoms. J Am Ger Soc 2022; 70(8): 2310-2319 First Published: 22 April 2022





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